Welcome to my clinic.

My name is Dr. Julianne Bingener and

I am the professor of surgery in the

Department of Surgery at Mayo

Clinic. Today, we're taking care

of a young patient with the

gastric greater curvature tumor

presumed to be a GIST tumor.

She would like to have it removed

and we would like to remove it

because it's increasing in size.

We are very concerned that maybe

ethnic pylorus off the stomach.

So it may be a little bit more

complex procedure.

I have assembled a great team, my

minimally invasive fellow, Dr. Blake

Bovitz, my resident Rebecca

Zhu, as well as my SA, CST

and nurse in the room are all

very facile with the robotic and

that endoscopic equipment.

Let's see, they have started now how

far they've gone.

We can make this skin incision here.

We'll make the first incision

vertically.

This one.

So typically, you'll go

here on this side

and then one here, if we need the

liver retractor here.

OK.

So we're doing a transversus

abdominal plane block.

We're performing a

robotic gastric GIST resection

today.

We're just about to place the

trocars for our case.

We've performed bilateral

tap blocks and

we're now put in two

ports on the left side of the

abdomen and one port on the right

side. If we need a liver retractor,

we will also place another

additional port on the right side

of the abdomen.

After we've done that, we will then

see what we can see of the tumor

and look also with the endoscope

to ensure where we are relative to

our pyloric portion

of the stomach.

So for the trocar placement, we

use the 30 up function off the

camera.

And once we begin our

gastric assessment, we'll use a 30

down function off the robotic

camera.

So we'll set the robot up for

docking from the

right side of the patient and upper

abdomen.

Very nice.

So we use the robotic function to

create a wireless

pairing between the robot

and the Trumph bed

that allows us to move

the patient bed while

the robot is docked.

It's an additional robotic upgrade.

OK. That's pretty nice.

Once we put the robotic camera in

there, we will be able to see

it. We will be able to touch it with

our tools.

And then I would expect to put the

endoscope through the mouth into

the stomach to see exactly

how far is the distance between the

tumor and the pylorous.

And so I will be able to see that

then, and hopefully there is a

reasonable distance between the

pylorus and the

tumor so that we can

place our staplers around that.

I will pull back the endoscope.

Staple.

Go back in with the endoscope

and see that the staple

where, where our stapler is actually

catches all the tumor, none of the

pylorus.

Once we have stapled and fired

everything, then I'll look back and

make sure that it's not bleeding.

Everything is fine from that

perspective.

And then we can take the rest of the

tumor out through the

robot.

So

now, in order to see the

distal gastric tumor, it seems like

we have to do some

adhesiolysis of the omentum from the

liver.

Can't quite see the tumor yet.

So he's retracting the distal

stomach and using

the vessel sealer to

perform adhesiolysis.

OK.

Adhesions lysed from that portion.

We still can't see the tumor.

So we'll get into the lesser

sac and see if we can, close to the

stomach, and then see if we can

find the tumor.

So this is the area, I think,

where you're starting to get close

to the stomach and to see if we can

follow. It's coming through here,

then. Yeah.

It's just so bulky, I didn't know

where the... Yeah, yeah, yeah so

lift it up a little bit and see,

there's epiploic and see if you can come

down here essentially along the

stomach. This is going to be the

plane here.

Yeah, yeah.

That's clearly posterior stomach.

That's lesser curve here.

You see that

right?

And so we don't want to go there.

Yeah.

That's your bubble.

So let's make sure that actually

connects to the stomach.

This looks like really nice.

Advance

without, without insufflating much

as you can.

It's hard, isn't it?

It's far, far out there.

He's far away.

Yeah, keep going. That's nice.

Keep going.

Just keep advancing.

There's only one way it can go

without resistance.

Keep going.

So she's using the scope to look

from within from the mouth, down the

esophagus and into the stomach, to

look from within inside at

the area that we're

seeing from the outside.

See what, to see if there's any

corresponding disease there to make

sure that when we remove that

portion of the stomach, that that's

included in what we remove.

It's

on the opposite side of the light.

Actually, probably. There you go.

All right. Very good, we can see you

now. And it's, there's nothing in

the lumen. Exactly.

And it's far away from the pylorus

as we can expect.

OK.

Here is the

lesser curve.

The little pedicle that it's on.

Yeah, exactly.

So you get there.

All right. Don't quit.

Don't squeeze it.

Good.

All right.

That looks good.

There you go. Open up.

Nice.

Now straighten out the stapler

before you pull it out.

Beautiful.

We're going to remove the specimen

through the Hassan

Port and then

place the Hassan trocar back in,

instead of the stapler,

and then we'll place a little stitch

in there, serosa.

So it was much more straightforward

than we had feared.

Which is good.

We were very concerned that the

tumor was involved

in the pylorus.

And after we finally had dissected

it free on the posterior wall of the

stomach, and it was unfolded,

we noticed that the pedicle was in

the body of the stomach where it was

very uncomplicated to put a stapler

underneath it and just resect it

and it was far away from the

pylorus. So it's hard to see on

imaging sometimes.

We were prepared for worse, but

it's good for her.

And we were able to do that.

Now we'll wait for the margins and

make sure that that's all clean and

hopefully complete the

procedure.